Eating disorders questionnaire Eating Disorders service questionnaire Note: Questions marked by * are mandatory The following questions are concerned with the past 4 weeks only (28 days). Please read each question carefully and tick the appropriate box. Please answer all the questions. *This is a mandatory field. Name *This is a mandatory field. Date of birth Email Telephone number On how many days out of the past 28 days: 0 days 1-5 days 6-12 days 13-15 days 16-22 days 23-27 days Every day *This is a mandatory field. 1. Have you been deliberately trying to limit the amount of food you eat to influence your shape or weight (whether you have succeeded or not)? *This is a mandatory field. 2. Have you gone for long periods of time (8 waking hours or more) without eating anything at all in order to influence your shape or weight? *This is a mandatory field. 3. Have you tried to exclude from your diet any foods that you like in order to influence your shape or weight (whether you have succeeded or not)? *This is a mandatory field. 4. Have you tried to follow definite rules regarding your eating (for example, a calorie limit) in order to influence your shape or weight (whether you have succeeded or not)? *This is a mandatory field. 5. Have you had a definite desire to have an empty stomach with the aim of influencing your shape or weight? *This is a mandatory field. 6. Have you had a definite desire to have a totally flat stomach? *This is a mandatory field. 7. Has thinking about food, eating or calories made it very difficult to concentrate on things you are interested in (such as working, following a conversation, or reading)? *This is a mandatory field. 8. Has thinking about shape or weight made it very difficult to concentrate on things you are interested in (such as working, following a conversation, or reading)? *This is a mandatory field. 9. Have you had a definite fear of losing control over eating? *This is a mandatory field. 10. Have you had a definite fear that you might gain weight? *This is a mandatory field. 11. Have you felt fat? *This is a mandatory field. 12. Have you had a strong desire to lose weight? Questions 13 to 18: Please fill in the appropriate number in the text box on the right. Over the past 4 weeks (28 days): *This is a mandatory field. 13. Over the past 28 days, how many times have you eaten what other people would regard as an unusually large amount of food (given the circumstances)? *This is a mandatory field. 14. On how many of these times did you have a sense of having lost control over your eating (at the time that you were eating)? *This is a mandatory field. 15. Over the past 28 days, on how many days have such episodes of overeating occurred (such as eating an unusually large amount of food and have had a sense of loss of control at the time)? *This is a mandatory field. 16. Over the past 28 days, how many times have you made yourself sick (vomit) as a means of controlling your shape of weight? *This is a mandatory field. 17. Over the past 28 days, how many times have you taken laxatives as a means of controlling your shape of weight? *This is a mandatory field. 18. Over the past 28 days, how many times have you exercised in a driven or compulsive way as a means of controlling your weight, shape or amount of fat, or to burn off calories? Questions 19 to 21: Please tick the appropriate box. Please note that for these questions the term binge-eating means eating what others of your age and gender would regard as an unusually large amount of food for the circumstances, accompanied by a sense of having lost control over eating. 0 days 1-5 days 6-12 days 13-15 days 16-22 days 23-27 days Every day *This is a mandatory field. 19. Over the past 28 days, on how many days have you eaten in secret (such as furtively)? Ignore episodes of binge eating. *This is a mandatory field. 20. On what proportion of the times that you have eaten have you felt guilty (felt that you’ve done wrong) because of its effect on your shape or weight? Ignore episodes of binge eating. *This is a mandatory field. 21. Over the past 28 days, how concerned have you been about other people seeing you eat? Ignore episodes of binge eating. Questions 22 to 28: Please tick the appropriate box using a number on the scale. Over the past 28 days: Not at all Slightly Moderately Markedly *This is a mandatory field. 22. Has your weight (number on the scale) influenced how you think about (judge) yourself as a person? *This is a mandatory field. 23. Has your shape influenced how you think about (judge) yourself as a person? *This is a mandatory field. 24. How much would it have upset you if you had been asked to weigh yourself once a week (no more, or less, often) for the next 4 weeks? *This is a mandatory field. 25. How dissatisfied have you been with your weight (number on the scale)? *This is a mandatory field. 26. How dissatisfied have you been with your shape? *This is a mandatory field. 27. How uncomfortable have you felt seeing your body (for example, seeing your shape in the mirror, in a shop window reflection, while undressing or having a bath or shower)? *This is a mandatory field. 28. How uncomfortable have you felt about others seeing your body (for example in communal changing rooms, when swimming, or wearing tight clothes)? *This is a mandatory field. What is your weight at present? Please give your best estimate. *This is a mandatory field. What is your height? Please give your best estimate). If female: Over the past 3 to 4 months have you missed any menstrual periods? If so, how many? Have you been taking the contraceptive pill? Thank you for completing this questionnaire * Spam Guard: What is 2+2? (Write the number as a word.)
